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Editorial
CASE REPORT
Journal of Orthopaedic Case Reports 2012 July-Sep;2(3):17-20
Closed Extension-Block Pinning for Management of
Mallet Fracture A Case Report Based Description
Sharat Agarwal1*, Nasim Mohammad Akhtar1
Abstract
Introduction: Close reduction by extension-block K-wire fixation for acute mallet fracture is based on two sound
orthopedic principles – stable arc splinting and early protected motion. Distal interphalangeal joint splinting is
still the technique commonly used for mallet fractures with significant morbidity and only moderate functional
outcome.
Case Report: We have demonstrated here Ishiguro's technique in a partially treated 2 weeks old mallet fracture
with the flexion deformity at distal interphalangeal (DIP) joint after proper preoperative assessment.
Peroperatively, proper anatomical localization of mallet fragment was done under fluoroscopy. Reduction of the
avulsion fracture was done by extension block K-wire and intra-articular K-wire was inserted subsequently to hold
the reduction in place and DIP joint in extension. Later on K-wires were removed at the end of 6 weeks follow up.
Patient was subjected to the physiotherapy during the course of the treatment. Excellent functional outcome was
noted at the end of three months.
Conclusion:Closed Extension block pinning can give acceptable functional outcome even in delayed mallet finger
injuries. Full range of movement at the affected joint is an important pre-requisite for the same.
Keywords: Mallet finger, Mallet fracture, Extension block method.
Introduction
Disruption of the extensor tendon mechanism of the
distal phalanx resulting in an extensor lag of the distal
interphalangeal joint is commonly referred to as a
'baseball or mallet finger deformity'. The underlying
mechanism of injury is axial loading of the distal
phalanx. There are three types of mallet finger injuries
namely the rupture of the extensor tendon, avulsion of
the extensor tendon at its attachment to the bone and the
avulsion fracture of dorsal base of the distal phalanx,
which is typically known as mallet fracture [1]. Mallet
injury with or without a bony defect is traditionally
1
North Eastern Indira Gandhi Regional Institute of Health &
Medical Sciences, Shillong, Mawdiangdiang-793012. India
Address of Correspondence
Dr. Sharat Agarwal
1
North Eastern Indira Gandhi Regional Institute of Health &
Medical Sciences, Shillong, Mawdiangdiang-793012. India
Email: [email protected]
treated with an immobilization splint in extension for
eight weeks, followed by night splinting for an additional
month. If the splint is removed and the distal
interphalangeal (DIP) joint of the finger goes into
flexion, the eight weeks splinting in extension must
start again [2]. It has been found that this management
protocol puts undue demand on patient compliance.
Cochrane review published online in 2008 found that the
most important factor in the success of splint treatment is
that of patient compliance [3]. On the other hand, open
repair is technically difficult and demanding. Close
reduction by extension-block K-wire pinning technique
described by Ishiguro for the management of Mallet
fractures[4, 5] is technically simple with good clinical
outcome.
Case History
A 29 year old male presented to us with pain and flexion
deformity of the DIP joint of the middle finger. There was
history of injury to left middle finger while playing
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Sharat A, Akhtar NM
Figure 1: Antero-posterior and lateral radiographs of (L) middle finger
showing mallet fracture with dorsally displaced intra-articular fracture
fragment from the base of the distal phalanx involving about 50 % of the
articular surface without comminution and volar subluxation of the distal
phalanx.
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cricket 2 weeks back. There was no history of open
injury. Patient had initially taken treatment at primary
health centre, where a finger splint was advised for 2
weeks. Subsequently, patient was subjected to
physiotherapy with mobilization of the distal
interphalangeal joint. On local examination there was
swelling with associated tenderness on the dorsal aspect
and flexion deformity of 20 degrees at distal
interphalangeal (DIP) joint of (L) middle finger. Further
flexion to 90 degrees was possible. There was no
restriction of passive extension. Antero-posterior and
lateral radiographs of (L) middle finger showed dorsally
displaced intra-articular fracture fragment from the
base of the distal phalanx involving about 50 % of the
articular surface without comminution and volar
subluxation of the distal phalanx (Fig. 1). Patient was
planned for close reduction by extension-block K
(Kirschner)-wire along with trans-articular K-wire
pinning of the DIP joint. Patient was operated under
digital block anesthesia on a radiolucent operating table
in supine position with intraoperative C-arm image
intensifier control. Being a closed procedure, no
tourniquet was used. With the DIP joint held in
maximum flexion, a 1.5 mm K-wire introduced just
behind the fracture fragment and driven proximally into
the head of the middle phalanx at an angle so that it
should not slip while insertion and it should get
purchase in the head of the middle phalanx and leaving
ample room for another transarticular K-wire. The
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fracture was reduced by the pressure of the proximal end
of the distal phalanx indirectly i.e. on the already
inserted K-wire levering the fracture fragment into its
original position as the DIP joint is brought into full
extension. Reduction was confirmed with C-arm image
intensifier. Another 1.5 mm K-wire was then advanced
through the distal phalanx across the DIP joint in
extension into the head of the middle phalanx to
maintain the reduction. Again, the reduction was
confirmed with the use of C-arm image intensifier. Kwires were bent and left protruding outside the skin to
facilitate removal later (Fig. 2). Pin tract dressing was
done following full aseptic technique. The PIP
(proximal interphalangeal) joint remained free and its
mobilization was started from day one postoperatively.
The wires were removed as an OPD procedure after 6
weeks and active mobilization of the DIP joint was
started. Night splinting of the finger with DIP joint in
extension was continued for another 2 weeks.
Subsequently passive mobilization was started after the
end of 8 weeks postoperatively. There was no pain or
extensor lag with full flexion of the DIP joint at the end
of 3 months follow up. Radiologically, no joint space
narrowing or joint incongruity was evident (Fig. 3). This
evaluation of the outcome was done on the basis of
Crawford criteria [6], which evaluates the results asExcellent- Full DIP joint extension, full flexion, no pain
Figure 2: Post-operative antero-posterior and lateral radiographs showing
in-situ extension-block and trans-articular K-wires. DIP joint is in slight
extension. Extension-block K-wire is radial-ward and trans-articular Kwire is ulnar-ward. Position of K-wires was dictated by position of the
mallet fragment as seen during intraoperative fluoroscopy.
Journal of Orthopaedic case reports | Volume 2 | Issue 3 | July – Sep 2012 | Page 17 - 20
Sharat A, Akhtar NM
www.jocr.co.in
Figure 3: Antero-posterior and lateral radiographs at 3 months follow up. No
extensor lag present. Joint space is congruous with no joint space
narrowing.
Good- 0-10 degrees of extension deficit, full flexion, no
pain; Fair- 10-25 degrees of extension deficit, any
flexion loss, no pain; Poor- More than 25 degrees of
extension deficit or persistent pain. In this case the
result was excellent as per Crawford's criteria , and
patient had full DIP joint extension, full flexion, no pain
with no medio-lateral instability.
Discussion
The dorsal intra-articular avulsion fracture of the base
of the distal phalanx or the bony mallet finger,
constitutes about 5 10 % of mallet finger injuries [7, 8].
The management of these injuries is dependent on the
size of the avulsed intra-articular fragment and
congruency of the DIP joint. The management of acute
mallet fingers with extensor tendon rupture or a small
fracture fragment involving less than one-third of the
articular surface of the distal phalanx is usually done by
continuous distal interphalangeal joint volar splinting
in extension with molded polythene (Stack) or
aluminum splint for 6 to 8 weeks. Night splinting
usually is recommended for an additional 2 to 6 weeks.
Commonly volar splints are used but dorsal splints can
also be used. However, care must be taken when
applying them to prevent maceration and ulceration of
the skin [9]. Conservative treatment has been advocated
by Wehbe and Schneider, regardless of the size of bony
fragment or extent of fracture displacement or
subluxation of the DIP joint. Good patient compliance
and regular follow-ups are essential [10]. Skin slough,
tape allergy, transverse nail plate grooves, splint-related
pain, and tender dorsal prominence can complicate
conservative treatment [11, 12]. However, the
management of mallet fractures involving more than
one-third of the articular surface has been found to be
more controversial. Wehbe and Schneider [10] observed
33% complication rate in open-surgically managed
group as compared to 9% in conservatively managed
group. The later group showed poor patient's
compliance as a major problem. Percutaneous pinning
procedures have decreased the complications associated
with open surgery. Most authors agree for operative
management for mallet fracture involving more than
one-third of the articular surface. But, open reduction is
fraught with many complications, like scar formation,
nail deformity, prominent dorsal bump, osteomyelitis,
non-union or avascular necrosis of the fragment, or
recurrent mallet or residual finger flexion deformity etc.
In 1988, Ishiguro et al introduced a new method for close
pinning by extension block for effective reduction of
mallet fragment and simultaneously decreasing the
complications of open surgery [5, 13]. Other authors
also confirmed the effectiveness of this technique [14,
15]. Ishiguro et al observed that the trans-articular Kwire should be introduced from the radial or ulnar side
to prevent the pin penetrating the fracture surface which
may lead to loss of reduction or interfere with fracture
healing [13]. In our case, intraoperative fluoroscopy
revealed that the mallet fragment was slightly radialwards, so the extension-block K-wire was placed on the
radial side, and the transarticular K-wire was placed
slightly towards ulnar side to attain good reduction and
to prevent transarticular pin coursing through fracture
line (Fig. 2). Understandably, pin-tract infection is one
of the potential complications of this technique, so due
pin-tract care is imperative. Removal of the callus in
chronic mallet fractures for correct anatomical
reduction is not possible by percutaneous techniques.
However, percutaneous procedures have been found to
be associated with the technical difficulty in accessing
the DIP joint correctly, achieving reduction of the small
articular fragment and potential chances of injury to the
tenuous soft tissue envelope [10, 13].
Journal of Orthopaedic case reports | Volume 2 | Issue 3 | July – Sep 2012 | Page 17 - 20
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Sharat A, Akhtar NM
www.jocr.co.in
Extension block pinning technique is a minimally
invasive method of managing mallet fractures with low
morbidity and good functional outcome. This technique
when properly applied has been found to produce
satisfactory functional results with good fracture union.
No issue related to patient compliance was noted. Good
pin-tract care is mandatory in these cases. Thus to
conclude, Ishiguro's extension-block K-wire fixation
technique is a novel method for the management of
Mallet fractures and should be considered for such
cases.
References
1. Doyle JR. Extensor tendon acute injuries. In: Green DP, Hotchkiss RN, Pederson
WC, eds. Operative hand surgery. 4th ed. New York: Churchill Livingstone, 1999;
1950-1987.
2. Perron AD, Brady WJ, Keats TE, et al. Orthopedic pitfalls in the emergency
department: closed tendon injuries of the hand. Am J Emerg Med 2001; 19: 76 80.
3. Handoll HH, Vaghela MV. Interventions for treating mallet finger injuries.
Cochrane Database Syst Rev. 2004;(3):CD004574.
4. Pegoli L, Toh K, Arai A, Fukuda S, Nishikawa S, Vallejo IG. The Ishiguro
extension block technique for the treatment of mallet finger fracture: indications
and clinical results. J Hand Surg 2003; 28B: 15-17.
5. Ishiguro T. A new Method of closed reduction for mallet fracture using
extension-block Kirschner wire. Cent Jpn J Orthop Trauma Surg 1988; 6: 413-5.
6. Crawford GP. The moulded polythene splint for the mallet finger deformities. J
Hand Surg Am. 1984; 9(2): 231-237.
Conclusion
This case report based review on the technique of the
management of Mallet Fracture using Closed Extension
block method has been presented to highlight the
efficacy and easiness to perform this procedure,
requiring attention to only few technical details with
good functional outcome.
Clinical Message
Closed Extension block pinning method can be successfully
used with good functional outcome for the management of
Mallet fracture with less than 1/3rd of the distal phalanx
involvement, presenting even as late as 2 weeks since injury.
Although, more number of cases may be required to
highlight the issue of the outcome, one key factor for a good
outcome can be the availability of full passive range of
motion at the DIP joint in the cases which are presenting late
to the treating surgeon especially in developing countries
7. Darder-Prats A, Fernandez-Garcia E, Fernandez-Gabarda R: Treatment of
mallet finger fractures by the extension-block K-wire technique. J Hand Surg [Br]
1998; 23(6): 802-805
8. Doyle JR: Extensor Tendons: Acute Injuries. In:Green DP (Ed.) Operative Hand
Surgery. New York: Churchill Livingstone, 1988; 3: 2045-71.
9. James H. Calandruccio, Mark T. Jobe. The Hand Fractures, Dislocations, and
Ligamentous Injuries. In: Campbell's Operative Orthopaedics, 11th ed.,
Philadelphia, Mosby Elsevier; 2008. p.3966-3967.
10. Wehbé MA, Schneider LH. Mallet fractures. J Bone Joint Surg Am. 1984; 66(5):
658-669.
11. Bendre AA, Hartigan BJ, Kalainov DM. Mallet finger. J Am Acad Orthop Surg.
2005; 13(5):336-344.
12. Stern PJ, Kastrup JJ. Complications and prognosis of treatment of mallet finger.
J Hand Surg Am. 1988; 13(3): 329-334.
13.Ishiguro T, Itoh Y, Yabe Y, Hashizume N. Extension block with Kirschner wire
for fracture dislocation of the distal interphalangeal joint. Tech Hand Up Extrem
Surg. 1997; 1(2): 95-102.
14. Inoue G. Closed reduction of mallet fractures using extension-block Kirschner
wire. J Orthop Trauma. 1992; 6(4): 413-415.
15. Darder-Prats A, Fernández-García E, Fernández-Gabarda R, Darder-García
A. Treatment of mallet finger fractures by the extension-block K-wire technique. J
Hand Surg Br. 1998; 23(6): 802-805.
How to Cite this Article:
Conflict of Interest: Nil
Source of Support: None
Sharat A, Akhtar NM. Closed Extension-Block Pinning for
Management of Mallet Fracture – A Case Report Based Description.
J Orthopaedic Case Reports 2012 July-Sep;2(3): 17-20
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Journal of Orthopaedic case reports | Volume 2 | Issue 3 | July – Sep 2012 | Page 17 - 20